Provider Demographics
NPI:1992106082
Name:GRACELIGHT COMMUNITY HEALTH
Entity type:Organization
Organization Name:GRACELIGHT COMMUNITY HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SNITMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:323-635-1153
Mailing Address - Street 1:4816 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90022-1602
Mailing Address - Country:US
Mailing Address - Phone:323-635-1153
Mailing Address - Fax:
Practice Address - Street 1:4816 E 3RD ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-1602
Practice Address - Country:US
Practice Address - Phone:323-780-4510
Practice Address - Fax:323-780-6132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-09
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACMM70660FMedicaid
CAW6997DOtherMEDICARE PROVIDER NUMBER
CA55-1019OtherMEDICARE FQHC PROVIDER NUMBER
CAPHY 52564OtherCALIFORNIA PHARMACY LICENSE